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Composite Declaration Form -11

(Tebe by the ploya jor juturerelference)
EMPLOYEES' PROVIDENT FUND ORGAN ISATION
loyees Provident Funds Scheme, 1952 (Paragraph 34 & 57)
Enzployees' pension Scheme, 19S (Paragraph 24)
(Ikclarationby a persz taking up employment ia y estabishment02 vüieà EPF 1952 and FÄ 1995 iapplicable)
Name of the member
Mahesh Band
Father's Nam
Name Venkah. Bandi
Date of Birth: ( DD MM YVYV)
08 2000
Gender: (MalefFemalerrransgender) Mole
Marital Status: (Maried] Unmaried/Widow/WidoweríDivorcee)
(a) Email I:
Siogle
6
bandimohesh 9203mall. tom
b'Mobile No.: ta8886A484
Present emp:oyment dewi!s:
Dale ofjoining in the curent establishment (DI)/MMYYYY) 29-03-2022
KYCDetails:(attach self attested copies offollowing KVCs)
a) Bank Account No.:
b) IFS Ccde ofthe branch:

c)AADHARNumber
d) Pertmnent Account Number (PAN). if available
q5529S7969 so
FDHPM225K
9
Wilether earlier a member of Employees' Provident Fund Scheme Ves:No
1952
10 Whether earlier amember of E | lovees'Pension Scheme, 1995 Yes/No
Previous employment details:lif Yes (a 9 AND/OR IC aboveltin-exempted
Establishment Universal PF Account Date ofjoining Date of exit Scheme PPO Number Nott
Name & Address Account Number (DDÆM (DDEMMf Ceziãcale if issued) Coatributory
Number VYYY) YYYY) issued Period
TCP_

11

Previous employment details: lif Yes (a 9 AND/OR IC abovel exempted - TRUST

Name & Address Universal PFAccount Date ofjoining Date of exit Scheme PPO Numbcr Nott
TRUST Account Number (DDEIMI (DDEMMf Ceztiäcale if issued) Coatnbutory
Number VYYY) YYYY) issued Period
12 CP

13 a) International Worker: Yes /No

 fyes, state country of origin (India:Name of other coun
c) Passport No.

a) Validity of DD/MWYYYY) to (DD/MWYYYY)I

UNDERTAKING

DCerliiCdthatthe particulars tolhc best

2) I authorize EPFO to IBC my Aadhar for purpose for Sta-vice delivery-
3) Kindly transferthcfnndsand service details, ifnpplicable, from the PI? accountasdeclared above to he
P.F
Account asam an Aadhar verificd employee in my previOlüs PF Account.
4) In case ofchanges in above details, the same win intimated to employer at the earliest.

Datc: 29-D3 2o
Place:
tyouvobad.

Signature ofMember

DECLARATION BY PRESENT EMPLOYER

TIC member Mr/Ms/Mrs hs joined on . - a n d has been

al 1Oüed PF No.- nd UAN

B. In casc the person was earlier not a mcmbzrcfEPF Scheme, ] 952 and EPS, 1995:

Please Tick the Appropriate Option:

The KYC details of the above member in the UAN database
Tlave not beenat-led
Have been uploaded but notppruved
Have been uploaded and approved with DSCJe-sign

C. In case the person was earlier a member ofEPF Scheme, 1952 and EPS, 1995:
Please Tick the Appropriate Option:-
E Ihc KYC details of the above member in the UAN have been approved wi(h E-siWDigita l Signalure
Certificate and transrer request has been generated on portal-
The previous Account of the znemtm is not Aadharvcrified and hence physical transfer fom shall be initiatzd.

Signature of Employer With Seal of

FAablishment

"Auto transfer ofprevious PF account would be ponsibie in respect ofAxihar verified emptoyees Only. Other employees arc requested to file

physical claim (Form- 13) KE transfer ofaccount from the previouscstab